Case Report

Primary oral tuberculosis: A case series of a rare disease

Rizwan Hamid1, Prenika Sharma1, Rayees Ahmad Sheikh1, Muzafar Bhat2
Departments of 1Oral Medicine and Radiology and 2Periodontics, GDC, Srinagar, Jammu and Kashmir, India

Abstract Tuberculosis (TB) is still one of the most life‑threatening infectious diseases, resulting in high mortality in
adults and is commonly found in developing countries. Lung is primarily affected while extrapulmonary
TB is rarely encountered. Oral lesions, although rare, can be seen in both primary and secondary stages
of TB. Primary oral TB may present a diagnostic challenge as its clinical features can be nonspecific that
mimics other diseases and is usually misdiagnosed. Thus, it is very important to be aware and be highly
suspicious of oral TB especially in endemic area. We share 4 such cases of primary oral TB with uncommon
presentations (two on the gingiva, one on the palate and one on the tongue) The diagnosis was made by
histopathological examination, polymerase chain reaction analysis and Mantoux test. They were successfully
treated with antituberculous treatment. In secondary TB, the oral manifestations may be accompanied
by lesions in the lungs, lymph nodes or in any other part of the body and can be detected by a systemic
examination.

Keywords: Gingiva, oral tuberculosis, palate, primary, tongue, tuberculosis

Address for correspondence: Dr. Rizwan Hamid, Department of Oral Medicine and Radiology, GDC, Srinagar, Jammu and Kashmir, India.
E‑mail: drrizwanhamid@gmail.com
Submitted: 01-Jun-2019, Revised: 04-Mar-2020, Accepted: 23-Mar-2020, Published: 09-Sep-2020

INTRODUCTION is usually presented as an ulcer. It has been hypothesized

Tuberculosis (TB) is still among the most life‑threatening
infectious diseases, resulting in high mortality in adults.[1]
It is a chronic infectious granulomatous disease caused by
Mycobacterium tuberculosis, an acid‑fast bacillus (AFB), and
less frequently by ingesting un‑pasteurized cow’s milk that
is infected by Mycobacterium Bovis or by other atypical
mycobacteria.[1] Both primary and secondary types of TB
can cause lesions in the oral cavity (OC).[2] In secondary
TB, lesions of the OC may accompany lesions in the
pharynx, lungs, lymph nodes or skin.[2] Extrapulmonary
TB accounts for 25% of the cases with 10%–35% detected
in the head and neck region.[3,4] Oral manifestation of TB
may affect people of all ages, especially the elderly, and
that auto‑inoculation may occur when the infected
pulmonary mucus interacts with wounded, susceptible
areas of the mucosa, eliciting the emergence of lesion.[5]
So far, cases of primary TB of the tongue are published
as an anecdotal case reports because of extreme rarity.[6]
Tubercular foci in OC secondary to primary TB of the lung
is again uncommon if not rare.[7] The incidence of oral
TB is only 0.1%–0.4%.[8] TB of OC even as a secondary
form is uncommon.[7] When oral lesions of TB are the
sole manifestations of the disease, the clinician may face
a diagnostic challenge.
The World Health Organization  (WHO) definition
of the case of extrapulmonary TB (EPTB) is: “any

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DOI: How to cite this article: Hamid R, Sharma P, Sheikh RA, Bhat M. Primary
10.4103/jomfp.JOMFP_174_19 oral tuberculosis: A case series of a rare disease. J Oral Maxillofac Pathol
2020;24:332-8.

332 © 2020 Journal of Oral and Maxillofacial Pathology | Published by Wolters Kluwer - Medknow
 Hamid, et al.: Primary oral tuberculosis – A case series of a rare disease
bacteriologically confirmed or clinically diagnosed case of
TB involving organs other than the lungs, e.g., pleura, lymph
nodes, abdomen, genitourinary tract, skin, joints and bones,
meninges.” From this definition are excluded the cases with
both pulmonary TB and EPTB, which are recommended
to be classified as pulmonary TB cases.[9,10] The lack of
specific pathognomonic signs makes the diagnosis of
EPTB to be often overlooked by the clinician.[2,11] Orofacial
TB is uncommon and presents at different sites such as
the mandible (alveolar and basal bone), head, face and
neck lymph nodes, tonsils, salivary glands, maxilla and
maxillary antrum, hard palate and soft tissues such as soft
palate, uvula, the gingiva, tongue, muscles of mastication
and buccal mucosa.[11,12] OC involvement is very rare and
was reported a long time ago. Morgagni described first case
of lingual TB in 1761.[6] De Paoli reported the first case
of parotid gland TB in 1893.[13] The incidence of TB in
underdeveloped countries is increasing, and this is thought
to be because of associated poor hygiene conditions and
the greater prevalence of AIDS.[14] Here, we report four
cases of primary oral TB (two on the gingiva, one on the
palate and one on the tongue). Clinical features of cases
are summarized in Table 1.
CASE REPORTS
Case 1
A 37‑year‑old female reported to the department of
oral medicine and radiology with a chief complaint of
nonpainful swelling of the upper anterior gingiva for the
past 8 months. The gingiva increased gradually in size with
time. The patient had a history of weakness over the past
3–4 months, loss of appetite and loss of weight of about
5 kg during the past 3 months. Her medical history revealed
no systemic problems, no cough with expectoration, no
known history of contact with a tuberculous patient and
no history of dental trauma or any surgery in the affected
area. On examination, she was of average built, pulse,
temperature and respiration rates were normal. Extraoral
examination revealed no cervical lymphadenopathy.
Intraoral examination showed diffuse enlargement of
labial maxillary gingiva (marginal and attached gingiva)
and alveolar mucosa extending from tooth number 13–23.
The gingiva was red, irregular, pebbled and granular
in appearance with surface ulceration [Figure 1a]. On
Table 1: Demographic and clinical characteristics
Case number Age (year) Gender
Case 1 37 Female
Case 2 45 Female
Case 3 23 Female
Case 4 49 Male
NUG: Necrotizing ulcerative gingivitis, NUP: Necrotizing ulcerative periodontitis, SCC: Squamous cell carcinoma
Journal of Oral and Maxillofacial Pathology | Volume 24 | Issue 2 | May-August 2020 333
palpation, the swelling was slightly tender, firm and had
a tendency for bleeding on provocation. The rest of
the OC was normal. Complete hemogram and IOPA
radiograph of 11, 12, 21 and 22 were advised. Results
were within normal limits, except for a marginal rise in
leukocyte count and an elevated erythrocyte sedimentation
rate (ESR). IOPA radiograph revealed interdental bone
loss in relation to 11 and 21. The patient was then
advised tuberculin test, chest X‑ray and sputum culture.
A tuberculin (Mantoux) test was positive, suggesting
tubercular infection. Chest radiography (posteroanterior
view) revealed no abnormalities [Figure 1b]. Culture of
sputum was negative for M. tuberculosis. An incisional
biopsy from the maxillary labial gingiva adjacent to
the central incisors was performed. Histopathological
examination revealed clusters of epithelioid cells,
caseating necrosis and numerous Langhans‑type giant
cells surrounded by a chronic inflammatory type of
infiltrate  [Figure  1c and d]. In view of these findings,
a working diagnosis of primary tuberculous gingival
enlargement was made. The patient was later administered
antitubercular regime, and within 2 months of therapy, the
lesion healed spontaneously [Figure 1e]. No recurrence
was observed even after 6 months of follow‑up. During
this period, the patient was instructed not to undergo any
surgical procedure within the OC. Further, conservative
periodontal therapy, which included scaling and root
planning, was carried out with minimal trauma to gingival
and after consulting the physician in‑charge.
Case 2
A 45‑year‑old female presented with a chief complaint
of painful ulcer on the palate for the last 1 year, which
gradually increased to the present size. She had received
antibiotics (amoxicillin plus clavulanate) prescribed by
local practitioners, but there was no response. She did
not have any systemic complaints such as cough, fever
or weight loss and had no history of any allergy. There
was no cervical lymphadenopathy or any other abnormal
findings. Intraoral examination revealed gingival ulcerations
involving marginal and attached gingiva in relation to
11–14 and mucosa of the anterior hard palate. The ulcer
is indurated, irregular, having an undermined margin and
a yellowish granular necrotic base [Figure 2a]. Owing
to suspicion of a malignant lesion, an incisional biopsy
Presented as Masquerading
Nonpainful swelling of the upper anterior gingiva NUG
Painful ulcer on palate NUG/NUP
Nonpainful swelling of the gingiva Gingival overgrowth
Painful and non‑healing ulcerated lesion of the tongue Oral SCC
 Hamid, et al.: Primary oral tuberculosis – A case series of a rare disease
was undertaken from anterior mucosa of hard palate
following the baseline investigations which were within
normal limits. Histopathological examination (HPE) of
the surgical specimen showed a conserved epithelium
covering the subepithelial layers, with widespread caseating
granulomas surrounded by lymphocytes, epithelial cells and
Langhans‑type giant cells [Figure 2b]. No neoplastic changes
were observed. Ziehl–Neelsen staining was negative. With
all these data, the diagnosis of oral TB was suggested
and systemic analyses were performed to determine its
primary or secondary origin. The Mantoux test showed
a positive reaction. Chest X‑ray did not show any lesion
suggestive of pulmonary TB. Three sputum specimens
were smear negative and culture negative. Although the
first clinical impression raised suspicion of a malignant
or traumatic process, these were both dismissed based on
the pathology results. In fact, the presence of caseating
granulomas surrounded by lymphocytes, epithelial cells and
Langhans‑type giant cells confirmed the diagnosis of TB.
The patient was referred to the department of infectious
a e
b c dd
Figure 1: (a) Red, irregular, pebbled and granular with surface
ulceration (b) chest radiograph showing absence of foci of infection.
(c) Photomicrograph showing granulomatous inflammation with
Langhanæs giant cells and focal caseous necrosis in H&E (×20).
(d) Photomicrograph showing Langhanæs giant cells in H&E
stain (×40). (e) Healing lesion (2 months after start of ATT)
a b
Figure 2: (a) Indurated irregular ulcer, having a yellowish granular necrotic base (b) histopathological slide showing giant cells (×40) (c) oral
lesions resolved within 4 weeks of treatment
334 Journal of Oral and Maxillofacial Pathology | Volume 24 | Issue 2 | May-August 2020
diseases for further management. Treatment was started
with isoniazid  (300  mg/day), rifampicin  (600  mg/day),
pyrazinamide (1500 mg/day) and ethambutol (900 mg/day)
for 2 months and the patient was asked to continue with
the first two drugs for the next 4 months. No pulmonary
signs and symptoms were present. The oral lesions resolved
within 4 weeks of treatment [Figure 2c]. The patient
was followed for 9 months after the treatment with no
recurrence of lesion.
Case 3
A 23‑year‑old girl reported to the department of oral
medicine and radiology with progressive, nonpainful
swelling of the gingiva on the labial aspect of the upper
and lower anterior teeth with 6 months’ duration. There
was a history of evening rise in temperature and weakness
over the last 3 months. The patient also had a loss of
appetite over the last 4 months and a weight loss of about
4.5 kg during the last 8 months. There were no systemic
problems, no cough with expectoration and no history of
dental trauma or surgery in the affected area. Extraoral
examination revealed no cervical lymphadenopathy.
Intraoral examination revealed diffuse enlargement of the
upper and lower gingiva on the labial surface of anterior
maxillary and mandibular teeth [Figure 3a]. On palpation,
the swelling was slightly tender and firm. The rest of the
OC was normal except for the few deep carious teeth.
Differential diagnoses were enlargement due to drugs,
infection and hematologic malignancy. The possibility of
drug‑induced enlargement was ruled out based on medical
history. The biochemical tests were within normal limits,
except for a marginal rise in leukocyte count (13 × 10 9/L)
and an elevated ESR of 56 mm/h (Westergren method),
which ruled out leukemia‑associated enlargement and
raised the possibility of one of the common causes of high
ESR, TB. An incisional biopsy was carried out under LA in
relation to the gingiva of the mandibular right central incisor,
in collaboration with the department of periodontics and
implantology. Histopathological examination was carried
out that revealed clusters of epithelioid cells surrounded
c
 Hamid, et al.: Primary oral tuberculosis – A case series of a rare disease

a b c

d e f
Figure 3: (a) Diffuse enlargement of both the arches and lobulated appearance of the mandibular labial gingiva extending up to the left first
molar (b) microscopic picture reveals numerous non‑caseating granulomas (×10) (c) histopathological picture of the lesion under ×40 magnification
reveals Langerhans giant cells and epithelioid cells (d) chest X‑ray does not reveal any abnormality (e) immediate post‑operative picture of the
lesion (f) intraoral picture after 1‑year follow‑up does not reveal any recurrence of the lesion

by a chronic inflammatory type of infiltrate. There was no
evidence of caseating necrosis, but numerous Langhans
giant cells were visible in the clusters of epithelioid cells
suggestive of a “hard tubercle” [Figure 3b and c]. To
eliminate the possibility of localized granulomatous changes
superimposed on an area of gingival enlargement, incisional
biopsy was repeated in the remaining three quadrants.
Histopathology showed similar granulomatous changes in
all tissue specimens examined. The tuberculin (Mantoux)
test was positive, suggesting tubercular infection.
Chest radiography (posteroanterior view) revealed no
abnormalities [Figure 3d]. A computed tomography scan of
the head and neck region was also performed to determine
the status of the underlying maxilla and mandible. The
scan did not reveal any bone abnormalities. A culture of
the sputum, obtained by forceful coughing, was negative
for M. tuberculosis. Special staining of formalin‑fixed,
paraffin‑embedded tissue specimens for Mycobacteria,
i.e., Ziehl–Neelsen and auramine–rhodamine stain, was
negative. An immunologic test to detect antibodies against
Mycobacterium in the patient’s serum (ELISA) was
positive. Polymerase chain reaction (PCR) assay was also
carried out using six 5‑µm sections of paraffin‑embedded
tissue to identify specific sequences of M. tuberculosis
complex, with adequate controls. The DNA was used as
an amplifying target for the sequence IS‑6110, which is
specific for M. tuberculosis. Positive PCR results confirmed
the presence of M. tuberculosis in the tissue samples. In view
of these findings, a final diagnosis of primary tuberculous
gingival enlargement was made. In consultation with the
patients’ physicians, antitubercular therapy (ATT) was
initiated. During this period, the patient was instructed
not to undergo any ultrasonic scaling and polishing or
surgical procedure within the OC and was warned about
the chance of transmitting the disease to others via aerosol
Journal of Oral and Maxillofacial Pathology | Volume 24 | Issue 2 | May-August 2020 335
and salivary contamination. After completion of a 6‑month
regimen of basic periodontal therapy, which included
scaling and root planning, oral hygiene instructions were
instituted under CDC‑issued guidelines. This resulted in
significant regression of the enlarged gingivae in both the
arches. Gingivectomy and gingivoplasty were performed to
shape and contour the residual enlargement under universal
aseptic conditions [Figure 3e]. No recurrence of lesion
occurred during 1‑year follow‑up [Figure 3f].
Case 4
A 49‑year‑old male was referred to our department with
the complaint of painful and non‑healing ulcer of the
tongue for 4 months. There was no history of fever, night
sweats, cough, decreased appetite and weight loss. He did
not give any history of traumatic episode preceding the
development of tongue ulcer. He denied any history of
similar lesions in the past. He is an occasional smoker. The
rest of his medical and surgical history was unremarkable.
His dental history was not significant. There was no history
of TB in his family members. He was repeatedly treated
in a government hospital with topical antiseptics and oral
antibiotics (ampicillin plus cloxacillin and metronidazole)
and analgesics, but the lesion did not subside so he was
referred to our hospital for the further management. On
general examination, he was of average built. Intraoral
examination revealed an indurated ulcer measuring
1.5 cm × 1.0 cm on the left dorsolateral border of anterior
part of tongue. It was tender on palpation with irregular
borders and did not bleed on touch. The remaining part of
the tongue appeared normal in texture and color. Mobility
of the tongue was normal. He had poor oral hygiene
along with sharp tooth in relation to 34. There were no
palpable cervical lymph nodes. Provisional diagnosis of
chronic traumatic ulcer was made as the possibility of
ulcer due to repeated trauma by the sharp tooth. Chest
 Hamid, et al.: Primary oral tuberculosis – A case series of a rare disease
X‑ray did not reveal any evidence of active lesion. Sputum
for AFB was negative on Ziehl–Neelsen stain. Complete
blood count was within normal limit. His ESR value was
20 mm/hr. Serum biochemistry and renal function tests
were within normal limits. Serological investigation for
human immune deficiency virus (HIV) was negative.
Coronoplasty of adjacent sharp cusps was done, and since
the ulcer presented for more than 2 months, an incisional
biopsy was taken under local anesthesia containing an
ulcerated lesion along with the normal looking margin
and the specimen was sent for HPE. Microscopically, the
lesion revealed the stratified squamous epithelium with
granulomatous inflammation containing Langhans‑type
giant cells, epithelioid cells and foci of caseous necrosis,
strongly suggestive of TB. The patient was then started
on ATT. The ulcer gradually started fading once drug
therapy was started (ATT) and the tuberculous ulcer
healed completely by the 2 months of ATT containing
isoniazid, rifampicin, pyrazinamide and ethambutol. The
patient was advised to continue ATT containing isoniazid
and rifampicin for another 4 months. At the end of total
6 month’s ATT course, there was no evidence of ulcer at
the primary site.
DISCUSSION
Primary TB (TB) of the OC, including tongue, is very
rare because of continuous cleaning of oral mucosa by
saliva and paucity of lymphoid follicles in tongue.[15‑17]
Secondary TB of OC is 0.2%–1.5% of extrapulmonary
TB cases.[18,19] The WHO estimates that 2 billion people
or one‑third of the world’s population are infected with
tuberculous bacilli and the global TB incidence is growing
at 1% a year.[15] Despite these staggering figures, TB of
the OC is rare.[15‑17] Furthermore, most cases of oral TB
are mainly secondary to pulmonary TB and rarely primary
in origin.[15] Such lesions are suspected to be caused by
implantation of infected sputum into a break in the
mucosal surface during coughing episodes. Transmission
during dental practice has also been described.[15] Clinical
manifestations of oral TB are varied and usually manifests
as nonhealing ulcer but can also appear as nodules,
swelling, fissures and as osteomyelitis of jaw bones. Oral
TB ulcers are usually single rather than multiple; they
have an indurated, irregular and undermined margin
with a necrotic base. The ulcer may be initially painless
but may become painful with the passage of time.[20]
Other manifestations of oral TB may include nodular
lesion or cold abscess.[6,19] Three forms of oral TB have
been described: acute miliary, chronic ulcerative and
lupus vulgaris.[21] Overwhelming majority (about 93%)
of the oral lesions are ulcers and approximately half
336 Journal of Oral and Maxillofacial Pathology | Volume 24 | Issue 2 | May-August 2020
of which affect the tongue.[22] Three of the cases in our
series were chronic ulcers and one presented as gingival
overgrowth. The ulcers were on the lateral margin of
tongue, anterior gingiva and anterior palate. Primary TB
of the OC is extremely rare and the published literature
is only in the form of case reports.[6,23,24] There appears
to be a geographical variation regarding which age group
is affected by primary TB. In Western literature, it is
mentioned that primarily oral TB affects children and
adolescents and is often associated with enlarged cervical
lymph nodes.[25] A few case reports from India also fall into
younger age group.[6,24] In this series, the mean age of the
patients was 38.5 years, while youngest being 23‑year‑old
female. TB of OC can be seen in adults, but primary TB
of lip and uvula among pediatric age group has been
reported occasionally.[24] Wang et al.[26] reported a series of
20 cases from Taiwan, wherein 55% of the patients were
older than 50 years and the most common location was
buccal mucosa and/or vestibule (5 cases), followed by the
alveolar mucosa (4), palate (2), lip (2) and tongue (1 case).
Rarely, direct inoculation may result in primary oral TB.
The site most commonly affected is the gingiva where
primary TB appears as a diffuse erythematous patch or
as diffuse gingival enlargement.[27] Primary TB of the OC
has been reported in HIV infected immune deficient cases
as an indicator of HIV infection; however, most of the
published literature pertains to cases with intact immune
status similar to the cases under discussion.[23,28] Other
TB lesions, diffuse glossitis or fissures, have also been
reported, but they are exceedingly rare.[29] Although the
dorsal surface is more commonly involved, involvement
of the ventral surface has also been described.[29]
The tuberculin sensitivity assay, also called Mantoux
test, is the standard procedure to diagnose TB. The assay
includes the intradermal inoculation of a purified protein
derivative of M. tuberculosis to assess the cellular immune
response to the antigens. An inflammatory reaction takes
place in M. tuberculosis sensitized patients. Inspection is
conducted after 2–3  days and is valid for 7  days. The
evaluation is based on the diameter of the inflammation
area measured transversally against the longitudinal
direction of the challenged forearm. An inflammation area
over 10 mm in immunocompetent subjects is considered a
positive result. In immunocompromised patients, an area
larger than 5 mm indicates TB. In turn, the minimum size
of inflammatory area in low‑risk individuals and children
under 15 years of age is 15 mm. Although the Mantoux
reaction is the method of choice in TB diagnosis, the
test has a few limitations, such as the low sensitivity in
immunocompromised patients (which points to the risk
of false negative results), the difficulty to use in children,
 Hamid, et al.: Primary oral tuberculosis – A case series of a rare disease
the subjective character of interpretations and the need
for a second appointment for confirmation purposes in
some cases.[30] The oral manifestation of TB may present as
an ulcerative, painless lesion on the palate, lips or tongue,
accompanied by persistent cervical lymphadenopathy.[29]
Our first case showed non painful ulcer on gingiva, second
one had painful ulcer on palate, third case had non painful
gingival swelling and the fourth one had painful ulcer
on tongue. The male:female ratio in our series was 1:3.
The differential diagnosis of TB ulcers includes a variety
of ulcerative diseases and conditions, such as squamous
cell carcinoma, traumatic ulcers, aphthous stomatitis,
syphilitic ulcers, actinomycosis, Wegener’s granulomatosis,
sarcoidosis, leishmaniosis, zygomycosis and Hansen’s
disease.[31] It is important to highlight that oral ulcers may
present a similar picture,[32] requiring a diagnosis based on
microscopic findings in addition to the Mantoux test and
bacilloscopy.[33] In our cases, aphthous ulcer was excluded by
the absence of initial multiple painful lesions and there was
no history of recurrent ulcers. Syphilitic ulcer was ruled out
by serology and silver staining done on tissue section. HIV
was ruled out by serology. Sarcoidosis was ruled out by the
absence of lung involvement on radiological examination
and presence of caseation and AFB on HPE. Diagnosis
of oral TB was based on HPE, PCR analysis and Mantoux
test.[34,35] Due to selective scarcity of bacilli within tissue,
mycobacteria can be demonstrated only in 27%–60% of
cases. Culture of mycobacteria had good result, but it lacks
sensitivity and takes 4–6 weeks.[34,36] Chest X‑ray is done
to exclude the possibility of pulmonary TB. Oral ulcers
may be indurated and is often painful (pain on deglutition,
burning sensation and otalgia). The gingival involvement is
the second form of oral TB after tongue TB.[25,37] For ulcers
of the tongue, deeper biopsies are mandatory. Biopsies as
superficial may not find the histopathological lesion due
to epithelial hyperplasia.[38] PCR assays as development
of DNA probes may use as more sensitive and rapid
diagnosis tests, but are more expensive. The risk for TB is
greater in patients with HIV infection than in non‑HIV.[39]
Our patients were HIV negative. During the treatment of
tuberculous pulmonary lesions, remission of tuberculous
ulceration of the tongue can appear together with remission
of lung TB lesions.[39] Lingual TB does not need surgical
resection and prognosis is favorable after antituberculous
treatment.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient(s) has/have
given his/her/their consent for his/her/their images and
other clinical information to be reported in the journal.
The patients understand that their names and initials will
Journal of Oral and Maxillofacial Pathology | Volume 24 | Issue 2 | May-August 2020 337
not be published and due efforts will be made to conceal
their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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